MONDAY MORNING, APRIL 22, 1968

8:30 A.M. Business Session (Limited to Members)

Ballrooms 1 and 2

8:45 A.M. Scientific Session: REGULAR PROGRAM

Ballrooms 1 and 2

1. Tissue Ingrowth and the Rigid Heart Valve: Review of Clinical and Experimental Experience During the Fast Year

Nina S. Braunwald, and Andrew G. Morrow, Bethesda, Md.

Previous studies in this laboratory indicated that a porous fabric lattice covering, which encouraged rapid tissue ingrowth, significantly decreased the incidence of thrombus formation on rigid prosthetic heart valves. Since February 1967, ball valves totally covered with fabric have been utilized clinically for replacement of the mitral and/or aortic valves. All aortic prostheses, and recently available mitral prostheses, have also had hollow metal poppets. To the date of this abstract, covered valves have been utilized in 26 patients for single or multiple valve replacements Warfarin has been administered for six weeks after operation, then discontinued. There have been no operative deaths, and no patient has evidenced systemic embolization. The rationale for the use of covered prostheses, including the desirability of early anticoagulation, will be supported by recent experimental data, and the total clinical experience with these valves at the National Heart Institute will be presented.

2. Studies of Deaths and Failures in 300 Cases of Valve Replacement

Pierre Grondin, Gilles Lepage, Claude Meere,* and

Yves Castonguay,* Montreal, Quebec

Through May 1967, 300 patients have undergone cardiac valve replacement at the Montreal Heart Institute. Several types of prostheses were used, including those of Starr, Gott, Hufnagel, Magovern and Cutter. This group consists of 127 mitral, 124 aortic, 2 tricuspid, 46 bivalvular and 1 trivalvular replacements. A near perfect follow up and a high percentage of necropsies have permitted a complete review of the deaths and failures. These will be presented in detail. It is rewarding to note that, in 95% of instances, a specific reason was found to explain death or failure. Many of the causes of death are preventable and a high proportion of the failures are correctable by a reintervention This emphasizes the need for complete investigation when physical incapacity persists after an otherwise successful operation.

3. Fresh Aortic Homografts for Multiple Valve Replacement

William W. Angell,* Albert B. Iben,* Edward B. Stinson,*

and Norman E. Shumway, Palo Alto, Calif.

Thromboembolism, hemorrhage, infection, and mechanical failure continue to be associated with prosthetic valve replacement. A solution to these problems may lie in the use of the fresh aortic homograft. Experimental Results: A total of 93 canine aortic valve transplants were placed in the subcoronary or atrioventricular position. Function was excellent with no evidence of valve deterioration. Clinical Results: Thirty-five patients underwent aortic valve replacement to the subcoronary position. Fresh aortic homografts were used as mitral replacement in fifteen patients There was no instance of hemodynamic insufficiency, and no valve failure. Four patients underwent homograft replacement for multiple valve disease. Three had double and one triple valve replacement with fresh aortic homografts. In mitral and tricuspid replacement the homograft valves were secured to homograft support rings specifically designed for this purpose. All patients have done well over two to four months with no complications related to the valve homografts. Conclusions: Fresh aortic homografts may be used directly in the subcoronary position or with a support ring in the atrioventricular position. Hospital mortality and operative complications for multiple homograft valve replacements are no greater than with the use of prosthetic valves.

4. Replacement of the Mitral Valve with Reinforced Aortic Heterografts: Technique and Results

Marian I. Ionescu,* Geoffrey H. Wooler,* and Stanley H. Taylor,*

Leeds, England

Sponsored by John W. Kirklin

Because of the disadvantages connected with the use of prosthetic valves the authors developed a technique for mitral valve replacement using heterologous aortic valves. Two types of grafts were used clinically. One of them, a reconstructed aortic valve, reinforced with a semi-rigid Teflon ring, was sutured above the mitral annulus inside the atrium. The second one, an aortic valve attached to a Dacron-covered titanium frame, was sutured to the mitral annulus. The technique of preparing and inserting these grafts is briefly described. Fifty patients were operated upon using this method. Except four, all had had one or more associated abnormalities. Eight patients died from causes not related to the graft. Two succumbed due to graft failure. Forty patients were greatly benefited by surgery. No embolisation occurred although anticoagulants were not used. Data concerning follow-up studies up to 14 months since the operation are presented to evaluate the results obtained (clinical condition, mechanograms, catheter findings, angiography). Technical and biological reasons for using this method are given. The long term fate of preserved aortic heterografts in the mitral position is discussed with clinical and experimental data.

5. Thoractomy on the Patient with Previous Malignancy: Metastasis or New Primary?

Paul C. Adkins, Conrad W. Wesselhoeft, Jr.,* William Newman,*

and Brian Blades, Washington, D.C.

Numerous reports have justified an aggressive surgical approach to the patient with a solitary pulmonary metastasis. However, not all lesions appearing in the chest of the patient who has been previously treated for a malignancy are metastatic. Forty-five patients with a past history of a primary malignancy elsewhere in the body have been seen with a solitary pulmonary or mediastinal lesion and subjected to thoracotomy. Thirty patients proved to have metastases to the lung associated with their original neoplasm. In the remaining 15 patients, or one-third of the total, the lesion was unrelated to the previous malignancy. Eight had new primary carcinomas and the remaining seven patients had benign lesions. In 14 patients with a history of carcinoma of the breast, a solitary pulmonary lesion was seen two to eleven years following mastectomy Seven (50%) of these were metastatic, two were benign granulomas and five were new primary pulmonary carcinomas. In some instances at the time of thoracotomy, it may be difficult for the pathologist to differentiate between a primary carcinoma and a metastatic lesion on frozen section. In this situation, we believe that the extent of the resection should be predicated on the strong possibility that one is dealing with a new primary pulmonary malignancy.

6. Scar Cancer of the Lung

Charles B. Ripstein, David Spain,* and Irwin Bluth,*

Brooklyn, N.Y.

Cancer developing in scars of the lung was first described by Rossle in 1939. Since that time examples have been reported in the literature in association with foreign bodies and the healed scars of tuberculosis, trauma and infarcts as well as pneumocomosis. The majority of scar cancers are adenocarcinomas of the bronchiole-alveolar type and they tend to remain localized for long periods before metastases occur. The prognosis following surgical excision is relatively favorable but early diagnosis presents a serious problem. This paper analyzes our experience in the management of 20 patients with scar cancer of the lung. A definite pattern of radiological criteria for diagnosis has emerged, and the x-ray findings have been correlated with the pathological features of the resected specimens. All patients have been treated by conservative resection of the involved area and follow-up examination confirms the impression that these tumors are slowly progressive and offer abetter prognosis than the usual forms of bronchogenic cancer.

7. Steroid Metabolism in Patients with Bronchogenic Carcinoma

J. Judson McNamara,* Harold H. Varon,* Donald L. Paulson,

Indira Shah,* and Harold C. Urschel, Jr., Dallas, Texas

Plasma and urinary steroid determinations were performed preoperatively and patients with subsequent tissue proof of bronchogenic carcinoma were included in the study. Control values were patients of similar age and sex with hiatus hernia. The protocol included 8:00 am. cortisol (70 carcinoma patients, 36 controls), 24 hour urinary hydroxy and ketosteroid determinations (70 carcinoma, 30 controls), ACTH stimulation tests (27 carcinoma patients), 24 hour total urinary estrogen excretion (31 carcinoma, 25 controls) and plasma cortisol determinations at 8 am.. 4 pm. and 10 pm. to evaluate daily variation in cortisol production (35 carcinoma, 25 controls). All patients had liver function studies. Those with abnormal values were dropped from study. Data was further divided with regard to sex, cell type, evidence of metastatic disease. Data shows two fold elevation in urinary estrogen excretion by male carcinoma patients (p 0.005). This difference was not observed for females. Estrogen excretion was greatest in males with squamous carcinoma and lowest with oat cell tumors. Five carcinoma patients had marked elevation of plasma cortisol values although cortisol values for the carcinoma group as a whole were not significantly elevated. The remaining pertinent data is presented in detail. The origin of the observed abnormalities and their implications on prognosis and treatment are discussed.

*By Invitation